Abstract
Importance: There is significant institutional variability in the intensity of end-of-life care that is not explained by patient preferences. Hospital culture and institutional structures (e.g., policies, practices, protocols, resources), might contribute to potentially non-beneficial high-intensity life-sustaining treatments near the end of life.
Objective: To understand the role of hospital culture in the everyday dynamics of high-intensity end-of-life care.
Design: Comparative ethnographic study. Data were deductively and inductively analyzed using thematic analysis through an iterative coding process.
Setting: Three academic hospitals in California and Washington that differed in end-of-life care intensity based on measures in the Dartmouth Atlas.
Participants: Hospital-based clinicians, administrators, and leaders
Main Outcome and Measure: Institution-specific policies, practices, protocols, and resources that shape hospital culture and their role in the everyday dynamics of potentially non-beneficial high-intensity life-sustaining treatments.
Results: We conducted 113 semi-structured, in-depth interviews with inpatient-based clinicians and administrators between December, 2018 and June, 2022. Respondents at all hospitals described default tendencies to provide high-intensity treatments that they believed was universal in American hospitals. They also reported that pro-active, concerted efforts among multiple care teams were required to de-escalate high-intensity treatments. Efforts to de-escalate were vulnerable to being undermined at multiple points during a patient’s care trajectory by any individual or entity. Respondents described institution-specific policies, practices, protocols, and resources that engendered broadly-held understandings of the importance of de-escalating non-beneficial life-sustaining treatments. Respondents at different hospitals reported different policies and practices that encouraged or discouraged de-escalation. They described how these institutional structures contributed to the culture and everyday dynamics of end-of-life care at their institution.
Conclusions and Relevance: Clinicians, administrators, and leaders at the hospitals we studied report that they work in a hospital culture where high-intensity end-of-life care constitutes a default trajectory. Institutional structures and hospital cultures shape the everyday dynamics by which clinicians may de-escalate end-of-life patients from this trajectory. Individual behaviors or interactions may fail to mitigate potentially non-beneficial high-intensity life-sustaining treatments if extant hospital culture or lack of supportive policies and practices undermine individual efforts. Hospital cultures need to be considered when developing policies and interventions to decrease potentially non-beneficial high-intensity life-sustaining treatments.
Objective: To understand the role of hospital culture in the everyday dynamics of high-intensity end-of-life care.
Design: Comparative ethnographic study. Data were deductively and inductively analyzed using thematic analysis through an iterative coding process.
Setting: Three academic hospitals in California and Washington that differed in end-of-life care intensity based on measures in the Dartmouth Atlas.
Participants: Hospital-based clinicians, administrators, and leaders
Main Outcome and Measure: Institution-specific policies, practices, protocols, and resources that shape hospital culture and their role in the everyday dynamics of potentially non-beneficial high-intensity life-sustaining treatments.
Results: We conducted 113 semi-structured, in-depth interviews with inpatient-based clinicians and administrators between December, 2018 and June, 2022. Respondents at all hospitals described default tendencies to provide high-intensity treatments that they believed was universal in American hospitals. They also reported that pro-active, concerted efforts among multiple care teams were required to de-escalate high-intensity treatments. Efforts to de-escalate were vulnerable to being undermined at multiple points during a patient’s care trajectory by any individual or entity. Respondents described institution-specific policies, practices, protocols, and resources that engendered broadly-held understandings of the importance of de-escalating non-beneficial life-sustaining treatments. Respondents at different hospitals reported different policies and practices that encouraged or discouraged de-escalation. They described how these institutional structures contributed to the culture and everyday dynamics of end-of-life care at their institution.
Conclusions and Relevance: Clinicians, administrators, and leaders at the hospitals we studied report that they work in a hospital culture where high-intensity end-of-life care constitutes a default trajectory. Institutional structures and hospital cultures shape the everyday dynamics by which clinicians may de-escalate end-of-life patients from this trajectory. Individual behaviors or interactions may fail to mitigate potentially non-beneficial high-intensity life-sustaining treatments if extant hospital culture or lack of supportive policies and practices undermine individual efforts. Hospital cultures need to be considered when developing policies and interventions to decrease potentially non-beneficial high-intensity life-sustaining treatments.
| Original language | English |
|---|---|
| Pages (from-to) | 839-848 |
| Number of pages | 10 |
| Journal | JAMA Internal Medicine |
| Volume | 183 |
| Issue number | 8 |
| DOIs | |
| Publication status | Published - 3 Jul 2023 |